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Coronary Heart Disease and Stroke Deaths — United States, 2009

Cathleen D. Gillespie, MS

Charles Wigington, MPH

Yuling Hong, MD,

National Center for Chronic Disease Prevention and Health Promotion, CDC


Corresponding author: Cathleen D. Gillespie, MS, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5855; E-mail: ckg2@cdc.gov.

Introduction

Heart disease and stroke are the first and fourth leading causes of death, respectively in the United States (1,2). In 2008, heart disease and stroke were responsible for nearly a third of all deaths in the United States (30.4%), killing more than three-quarters of a million people that year (1). Coronary heart disease (CHD) is the cause of more than two-thirds of all heart disease-related deaths (1,2). One of the Healthy People 2020 objectives includes reducing the rate of CHD deaths by 20% from the baseline rate of 126 deaths per 100,000 population per year, to a goal of 100.8 deaths per 100,000 (objective HDS-2) (3). The objectives also include reducing the rate of stroke deaths by 20% over the baseline of 42.2 deaths per 100,000, to a goal of 33.8 deaths per 100,000 population. Although the rates of death from both CHD and stroke have declined continuously in recent decades and the Healthy People 2010 goals for these two objectives were met among the overall U.S. population in 2004, the death rates remain high, particularly among men and blacks (4–6).

This heart disease and stroke analysis and discussion that follows is part of the second CDC Health Disparities and Inequalities Report (2013 CHDIR) (6). The 2011 CHDIR (7) was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria described in the 2013 CHDIR Introduction (8). This report provides more current information on CHD and stroke deaths among different age and racial/ethnic groups. The purposes of the coronary heart disease and stroke mortality report are to discuss and raise awareness of differences in the characteristics of persons dying from coronary heart disease and stroke, and to prompt actions to reduce disparities.

Methods

To examine the number and age-specific CHD and stroke mortality rates of persons of all ages, by sex, age group, and race/ethnicity, CDC analyzed final 2009 data from the National Vital Statistics System (NVSS). NVSS data are described in detail elsewhere (http://www.cdc.gov/nchs/nvss.htm). Race was defined as white, black, American Indian/Alaska Native (AI/AN), and Asian/Pacific Islander (A/PI). Ethnicity was defined as Hispanic or non-Hispanic. Sociodemographic information beyond age, sex, and race/ethnicity is not available in the NVSS.

CDC estimated the number of deaths and the rate of death per 100,000 population for which coronary heart disease or stroke were the underlying cause of death (ICD-10 codes I20–I25 for CHD, I60–I69 for stroke), and 95% confidence intervals were calculated based on a Poisson distribution, consistent with NCHS methodology (1). Rates per 100,000 population were age-adjusted to the 2000 U.S. standard population, except where stratified by age group (9). Disparities were measured as the deviations from a "referent" category rate and by characteristics that included sex, age, and race/ethnicity. Absolute difference was measured as the simple difference between a population subgroup estimate and the estimate for its respective reference group. The relative difference, a percentage, was calculated by dividing the difference by the value in the referent category and multiplying by 100. Significant differences between rates were determined by nonoverlapping 95% confidence intervals. All tests for differences in age-adjusted death rates were significant compared with the indicated referent group after Bonferroni adjustment for multiple comparisons.

Results

The age-adjusted rate of death from CHD in 2009 was 116.1 per 100,000 population (Table), and CHD was listed as the underlying cause of death in 386,324 persons in the United States. The age-adjusted death rate per 100,000 population from CHD was higher among men than women (155.8 versus 86.2) and higher among non-Hispanic blacks (141.3) than among any other racial/ethnic group. The rate of premature death (death among persons aged <75 years) was higher among non-Hispanic blacks than their white counterparts (65.5 versus 43.2).

Similar differences were observed for deaths from stroke, which was listed as the underlying cause of death in 128,842 persons in the United States in 2009, an age-adjusted rate of 38.9 deaths per 100,000 population. The age-adjusted death rate per 100,000 population from stroke was higher among non-Hispanic blacks (73.6) than among any other racial/ethnic group. The rate of premature death (death among persons aged <75 years) from stroke was higher among non-Hispanic blacks than their white counterparts (25.0 versus 10.2).

Discussion

Although death rates from CHD and stroke are declining overall (4), disparities still remain in the rate of death from these events between racial/ethnic groups. The premature death rate from CHD and stroke continues to be higher among black adults than their white counterparts. The Healthy People 2020 objectives and goals for heart disease and stroke are intended to reduce premature deaths by promoting prevention of these events and reducing their recurrence. In 2011, CDC launched the Million Hearts initiative, which is intended to bring together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country to prevent 1 million heart attacks and strokes over 5 years.

Limitations

The findings in this report are subject to at least three limitations. First, misclassification of race and ethnicity of the decedent on the death certificate might underestimate rates among AI/ANs, A/PIs, and Hispanics (10). Second, results from a study in New York City, New York, indicated that CHD is overreported as a cause of death on death certificates (11). However, these results might be specific to New York City. Third, the death rates reflect only the underlying cause of death and no other contributing causes of death such as diabetes, which vary substantially across racial/ethnic groups.

Conclusion

Risk factors for cardiovascular disease include tobacco use, physical inactivity, poor diet, diabetes, obesity, hypertension, and dyslipidemia. Preventing or controlling hypertension and high low-density lipoprotein (LDL) cholesterol have been shown to greatly reduce the risk for stroke and CHD, respectively (12,13). In 2011, the U.S. Department of Health and Human Services launched the Million Hearts initiative to prevent 1 million heart attacks and strokes by the year 2017, through focused clinical and policy strategies. The Guide to Community Preventive Services Task Force recommends system interventions to improve CVD risk factors, including clinical decision support systems, reducing out-of-pocket costs for CVD preventive services for patients with hypertension and high cholesterol, and team-based care to improve blood pressure control. The United States Preventive Services Task Force (USPSTF) recommends blood pressure screening for all adults aged ≥18 years and LDL-cholesterol screening for adults in certain sex, age, and heart disease risk groups (14,15). As a result of provisions in the Patient Protection and Affordable Care Act, USPSTF-recommended clinical preventive services covered by Medicare now have no patient cost sharing (§4104) (16,17). The law also requires that "nongrandfathered" private health plans include these same services without cost sharing (§1001) and encourages Medicaid to cover them through an increase in the federal matching rate for those services (§4006). Because the rates of premature death from CHD and stroke are higher among blacks, it will be important to monitor this and other vulnerable population groups (i.e., those with limited access to regular medical care) to determine if improvements are evident in the future.

References

  1. Miniño AM, Murphy SL, Xu J, Kochanek KD. Deaths: Final data for 2008. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2011. National Vital Statistics Report, vol 59, no 10. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.
  2. Murphy SL, Jiaquan Xu J, Kochanek KD. Deaths: Preliminary Data for 2010. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2011. National Vital Statistics Report, vol 59, no 10. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf.
  3. US Department of Health and Human Services. Healthy people 2020. Available at http://www.healthypeople.gov/2020/default.aspx.
  4. Hoyert DL. 75 Years of mortality in the United States, 1935–2010. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2012. NCHS Data Brief no 88. Available at http://www.cdc.gov/nchs/data/databriefs/db88.pdf.
  5. CDC. Healthy people data 2010: the healthy people database. Atlanta, GA: US Department of Health and Human Services, CDC: 2010. Available at http://wonder.cdc.gov/data2010.
  6. CDC. Coronary heart disease and stroke deaths—United States, 2006. In: CDC. CDC health disparities and inequalities report. MMWR 2011;60(Suppl; January 14, 2011).
  7. CDC. CDC health disparities and inequalities report—United States, 2011. MMWR 2011;60(Suppl; January 14, 2011).
  8. CDC. Introduction. In: CDC health disparities and inequalities report—United States, 2013. MMWR 2013;62(No. Suppl 3)
  9. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2001. NCHS Statistical Notes no 20. Available at http://www.cdc.gov/nchs/data/statnt/statnt20.pdf.
  10. Arias E, Schauman WS, Eschbach K, Sorlie PD, Backlund E. The validity of race and Hispanic origin reporting on death certificates in the United States. National Center for Health Statistics. Vital Health Stat 2(148);2008.
  11. Agarwal R, Norton JM, Konty K, et al. Overreporting of deaths from coronary heart disease in New York City hospitals, 2003. Prev Chronic Dis 2010:A47. Available at http://www.cdc.gov/pcd/issues/2010/may/09_0086.htm.
  12. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;43:1206–52.
  13. National Institutes of Health. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Executive Summary. Heart, Lung, and Blood Institute. National Institutes of Health. NIH Publication No. 01–3670. May 2001. Available at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm.
  14. Agency for Healthcare Research and Quality. Screening for high blood pressure. Available at http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm.
  15. Agency for Healthcare Research and Quality. Screening for lipid disorders in adults. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm.
  16. US Department of Health and Human Services. Patient Protection and Affordable Care Act of 2010. Pub. L. No. 114–48 (March 23, 2010), as amended through May 1, 2010. Available at http://www.healthcare.gov/law/full/index.html.
  17. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. New Engl J Med 2010;363:1296–9.

TABLE. Number of deaths and age-adjusted death rates* from persons within coronary heart disease and stroke§ by sex, age, and race/ethnicity — National Vital Statistics System, United States, 2009

Coronary heart disease

No.

Age-adjusted (except where noted)

Rate*

(95% CI)

Absolute
difference
(rate)

Relative
difference
(%)

Total

386,324

116.1

(115.7–116.5)

Male

210,069

155.8

(155.2–156.5)

Ref.

Ref.

Female

176,255

86.2

(85.8–86.6)

-69.6

-44.7

Age in years

<45

6,679

3.9

(3.8–4.0)

-129.3

-97.1

0–24

150

0.1

(0.1–0.2)

25–44

6,529

8.4

(8.2–8.6)

45–74

131,632

133.2

(132.5–133.9)

Ref.

Ref.

45–54

23,285

52.2

(51.5–52.9)

55–64

46,018

132.3

(131.1–133.5)

65–74

62,329

299.8

(297.4–302.2)

<75

138,311

43.5

(43.3–43.8)

≥75

247,990

1,245.80

(1,240.8–1,250.7)

1112.6

835.3

≥85 (crude)

143,204

2543.3

(2,530.1–2,556.5)

Race/Ethnicity

Hispanic**

20,228

86.5

(85.3–87.7)

-31.2

-26.5

Non-Hispanic

365,119

118.2

(117.8–118.6)

White, non-Hispanic

315,810

117.7

(117.3–118.1)

Ref.

Ref.

Black, non-Hispanic

39,956

141.3

(139.9–142.8)

23.6

20.1

American Indian/Alaska Native

1,737

92

(87.5–96.5)

-25.7

-21.8

Asian/Pacific Islander

7,616

67.3

(65.8–68.8)

-50.4

-42.8

Age in years/race-ethnicity

<45 years

Hispanic**

561

1.9

(1.7–2.0)

-2.2

-53.7

Non-Hispanic

6,094

4.3

(4.2–4.4)

White, non-Hispanic

4,459

4.1

(4.0– 4.3)

Ref.

Ref.

Black, non-Hispanic

1,369

6.2

(5.9–6.5)

2.1

51.2

45–74

Hispanic**

8,176

98

(95.8–100.2)

-33.5

-25.5

Non-Hispanic

122,907

136.1

(135.3–136.9)

White, non-Hispanic

99,389

131.5

(130.7–132.3)

Ref.

Ref.

Black, non-Hispanic

19,820

199.5

(196.7–202.3)

68

51.7

<75

Hispanic**

8,737

31.3

(30.7–32.0)

-11.9

-27.5

Non-Hispanic

129,001

44.7

(44.5–45.0)

White, non-Hispanic

103,848

43.2

(42.9–43.5)

Ref.

Ref.

Black, non-Hispanic

21,189

65.5

(64.6–66.4)

22.3

51.6

≥75

Hispanic**

11,490

945.7

(928.4–963.0)

-331.6

-26

Non-Hispanic

236,100

1,262.9

(1,257.8–1,268.1)

White, non-Hispanic

211,949

1,277.3

(1,271.8–1,282.8)

Ref.

Ref.

Black, non-Hispanic

18,763

1,322.8

(1,303.9–1,341.8)

45.5

3.6

≥85

Hispanic**

5,793

1,787.5

(1,741.5–1,833.5)

-841.1

-32

Non-Hispanic

137,234

2,586.1

(2,572.4–2,599.8)

White, non-Hispanic

125,303

2,628.6

(2,614.0–2,643.2)

Ref.

Ref.

Black, non-Hispanic

9,085

2,555.2

(2,502.7–2,607.7)

-73.4

-2.8


TABLE. (Continued) Number of deaths and age-adjusted death rates* from persons within coronary heart disease and stroke§ by sex, age, and race/ethnicity — National Vital Statistics System, United States, 2009

Stroke§

 No.

Age-adjusted (except where noted)

Rate*

(95% CI)

Absolute
difference
(rate)

Relative
difference
(%)

Total

128,842

38.9

(38.7–39.1)

Male

52,073

39.7

(39.3–40.0)

Ref.

Ref.

Female

76,769

37.8

(37.5–38.1)

-1.9

-4.8

Age in years

<45

2,914

1.6

(1.6–1.7)

-33.4

-95.4

0–24

461

0.4

(0.4–0.5)

25–44

2,453

3.1

(3.0–3.2)

45–74

34,264

35

(34.6–35.3)

Ref.

Ref.

45–54 (crude)

6,163

13.8

(13.5–14.1)

55–64 (crude)

10,523

30.2

(29.6–30.8)

65–74 (crude)

17,578

84.5

(83.3–85.7)

<75

37,178

11.9

(11.7–12.0)

≥75

91,660

460.1

(457.1–463.1)

425.1

1,214.6

≥85 (crude)

53,253

945.8

(937.8–953.8)

Race/Ethnicity

Hispanic**

7,065

29.5

(28.8–30.2)

-8.3

-22.0

Non-Hispanic

121,540

39.5

(39.3–39.7)

White, non-Hispanic

101,703

37.8

(37.5–38.0)

Ref.

Ref.

Black, non-Hispanic

15,718

55.7

(54.8–56.6)

17.9

47.4

American Indian/Alaska Native

533

29.8

(27.2–32.4)

-8

-21.2

Asian/Pacific Islander

3,586

31.6

(30.6–32.7)

-6.2

-16.4

Age in years/race-ethnicity

<45 years

Hispanic

498

1.5

(1.4–1.6)

0.2

1.5

Non-Hispanic

2,406

1.7

(1.6–1.7)

0.4

3.1

White, non-Hispanic

1,439

1.3

(1.3–1.4)

Ref.

Ref.

Black, non-Hispanic

796

3.5

(3.2–3.7)

2.2

16.9

45–74

Hispanic

2,654

31.5

(30.3–32.7)

1.2

0.4

Non-Hispanic

31,506

35.2

(34.8– 35.6)

White, non-Hispanic

22,699

30.3

(29.9–30.7)

Ref.

Ref.

Black, non-Hispanic

7,338

73.6

(71.9–75.3)

43.3

142.9

<75

Hispanic

3,152

10.7

(10.3–11.1)

0.5

0.5

Non-Hispanic

33,912

12

(11.8–12.1)

White, non-Hispanic

24,138

10.2

(10.1–10.3)

Ref.

Ref.

Black, non-Hispanic

8,134

25

(24.4–25.5)

14.8

14.5

≥75

Hispanic

3,913

322.5

(312.4–332.6)

-144

-30.9

Non-Hispanic

87,624

468.3

(465.1–471.4)

White, non-Hispanic

77,562

466.5

(463.5–469.8)

Ref.

Ref.

Black, non-Hispanic

7,584

534.5

(522.5–546.5)

68

14.6

≥85 (crude)

Hispanic

1,901

586.6

(560.2–613.0)

-387.3

-39.8

Non-Hispanic

51,292

966.6

(958.2–975.0)

White, non-Hispanic

46,426

973.9

(965.0–982.8)

Ref.

Ref.

Black, non-Hispanic

3,619

1,017.9

(984.7–1,051.1)

44

4.5

Abbreviations: 95% CI = 95% confidence interval; Ref = referent.

* Per 100,000. Directly standardized to the 2000 U.S. standard population, except where stratified by age.

ICD-10 codes: I20–I25

§ ICD-10 codes: I60–I69

All tests for differences in age-adjusted death rates were significant compared with the indicated referent group after Bonferroni adjustment for multiple comparisons.

** Persons of Hispanic ethnicity might be of any race or combination of races.


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